Management of Recurrent Febrile UTIs in a Patient with CKD and Ileal Conduit After Radical Cystectomy
A comprehensive evaluation of the upper and lower urinary tracts with imaging and cystoscopy is strongly recommended for this patient with chronic kidney disease experiencing recurrent febrile UTIs after radical cystectomy with ileal conduit. 1
Diagnostic Evaluation
- Obtain urinalysis and urine culture during each symptomatic episode to guide targeted antimicrobial therapy 2, 1
- Collect urine specimens properly by changing the catheter and allowing for urine accumulation while plugging the catheter; never obtain specimens from extension tubing or collection bag 2, 1
- Perform upper tract imaging (CT urography or MR urography) to evaluate for potential complications such as stones, hydronephrosis, or other anatomic abnormalities 2, 1
- Consider cystoscopic examination of the ileal conduit to identify potential sources of infection such as retained sutures, stones, or other foreign bodies 2, 1
- Evaluate for ileal conduit stenosis, which can develop insidiously years after diversion and may be causing upper urinary tract damage 3
Treatment Approach
- Treat each symptomatic UTI with appropriate antibiotics based on culture results and local resistance patterns, with dosing adjusted for the patient's renal function (CKD with creatinine of 2.2) 1
- Consider urodynamic evaluation since recurrent UTIs persist despite previous interventions 2
- Evaluate for incomplete emptying of the ileal conduit, which may contribute to recurrent infections 2, 1
Prevention Strategies
- Daily antibiotic prophylaxis is not recommended routinely, as this may increase bacterial resistance without significantly reducing symptomatic infections 2, 1
- Consider methenamine hippurate for UTI prevention, though evidence in ileal conduit patients is limited 1
- Ensure proper stoma care, as inadequate stoma care routines are associated with higher rates of complications including infections 3
- Monitor for hydronephrosis, as a history of hydronephrosis is an independent risk factor for CKD in patients with ileal conduit urinary diversion 4
Risk Factors and Special Considerations
- CKD patients with ileal conduit have significantly higher rates of adverse outcomes, requiring particularly careful management 5
- Female sex has been identified as a risk factor for febrile UTIs in patients with ileal conduit 6
- Gram-positive strains (particularly Enterococcus faecalis and Staphylococcus species) account for approximately 60% of pathogens causing febrile UTIs after radical cystectomy, with gram-negative strains (E. coli, Pseudomonas) accounting for about 37% 6
- Palliative cystectomy, prior radiation therapy, and longer time from diagnosis to cystectomy have been associated with higher risk of complicated UTIs 7
Follow-up Recommendations
- Schedule regular follow-up with upper tract imaging to monitor for complications, especially given the patient's chronic kidney disease 1
- Monitor renal function closely, as patients with ileal conduit urinary diversion show an average decrease in estimated glomerular filtration rate of 0.95±2.0 ml/min/1.73 m² per year 4
- Instruct the patient to seek prompt medical evaluation for future febrile episodes 1
- Do not perform surveillance urine cultures in asymptomatic periods, as this may lead to unnecessary antibiotic treatment 1
Pitfalls and Caveats
- Avoid treating asymptomatic bacteriuria, as this promotes antimicrobial resistance without clinical benefit 1
- Be vigilant for urolithiasis and hydronephrosis, as these are independent risk factors for CKD progression in patients with ileal conduit 4
- Consider that stenosis of the ileal conduit can develop insidiously many years after the diversion and may be the cause of upper urinary tract damage 3